insights (2007-43)

More Accessible Health Care

Metro Pulse Staff

11:00 PM, Oct 24, 2007

insights

When Gov. Phil Bredesen curtailed TennCareâ’s expansive eligibility standards in 2004, among those who lost their coverage were some 60,000 enrollees classified as uninsurable. These individuals, who had been denied commercial health insurance because of their medical conditions, were left for a time without access to any other type of coverage.

Earlier this year, however, the Bredesen administration rolled out a program known as Access TN that offered subsidized benefits to these and otherwise uninsurable people who could afford its premiums. Yet after six months of availability, only about 2,000 individuals have signed up; and at this enrollment level much of the $23 million state appropriation for the program in the current fiscal year is likely to go unspent.

The biggest deterrent to a larger uptake appears to be affordability. Even though they are subsidized, posted premiums for inclusion in this â“high-risk pool,â” range from roughly $400 to $1,000 a month depending on a personâ’s age, weight and tobacco use. For low income applicants, the state has offered premium assistance that ranges up to 70 percent of the posted rate for those with incomes below the federal poverty line (FPL) of about $10,000. But for a fifty-something-year-old, non-obese, non-smoker below the FPL, that still equates to an out-of-pocket expense of $2,340 a year for average with a $1,000 deductible. As a rule, premiums in excess of 10 percent of incomeâ"$1,000 in this caseâ"are deemed unaffordable.

Starting January, however, Access TN premium assistance is due to increase to 90 percent for persons below the FPL. So the hypothetical out-of-pocket expense of $2,340 or above will come down to less than $800 a year, making coverage more affordable. And thatâ’s not the only way in which the program is being made more beneficial to individuals with conditions that have otherwise precluded their getting health insurance.

Up to now, Access TN hasnâ’t covered pre-existing conditions during the first six months of enrollment. But again effective Jan. 1, this pre-existing exclusion will only apply to 50 percent of expenses incurred during those six months. And for cancer victims, there wonâ’t be any exclusion at all for the cost of chemotherapy and radiation treatment.

Even one of the harshest critics of adverse TennCare disenrollment consequences, Tony Garr of the Tennessee Health Care Coalition, acknowledges the improvements. â“Both the 90 percent premium assistance and getting 50 percent coverage immediately will really help a lot,â” he says.

Equally encouraging, as many as 50,000 medically needy Tennesseans should soon benefit from the reopening of a category of TennCare eligibility thatâ’s been closed since 2005. These medically needy are defined as adults whose accumulated medical bills would drive down their incomes and net worth (exclusive of their homes) below federally set minimums. Once theyâ’ve â“spent downâ” to these minimums, Medicaid in most states covers the balance of their bills for up to 12 months at a time. Closing this category of eligibility (except to children and pregnant women) was perhaps the most draconian element of Bredesenâ’s 2005 TennCare cutbacks.

As part of a settlement that freed the state from what Bredesen contended were unwarranted court-ordered constraints, the governor agreed to reopen the window for the medically needy subject to a 100,000 cap on enrollment (some 50,000 remain on the rolls because they were grandfathered). The onus for the two-year delay in getting it reopened rests much more with the federal centers for Medicare and Medicaid Services (CMS) than with the state. Indeed, it became one part of an enormously complex negotiating process with CMS thatâ’s been enormously frustrating to state officials.

Earlier this month, the parties finally reached a comprehensive agreement on the terms of whatâ’s known as the waiver under which TennCare will operate for the next five years. Federal matching funds, especially for Medicaid reimbursements to hospitals that serve a disproportionate share of poor people, will cut back, but not by as much as CMS has sought. Despite cuts, Bredesen needs to proceed with reopening the window for the medically needy soon, though no date has been set. Eligibility for the $50,000 medical slots is limited to adults with disabilities severe enough to qualify for federal Social Supplemental Income (SSI), and not that many of the 61,000 considered uninsurable disenrolled from TennCare may fit. In 2006, the State Legislative appropriated $28 million toward seeking federal matching funds to cover them under a new Medicaid waiver program.

Iâ’ve been critical of Bredesen in the past for not pursuing these matching funds. But given the stateâ’s horrific experience getting its TennCare waiver extended, the governorâ’s aversion to new federal entanglements may be justified.

With state funds to spare, Access TNâ’s spokesperson, Dean Flener is actively encouraging more enrollment. â“Please tell your readers to call (866) COVERTN to get applications and help with their completion,â” Flener says. â"
Joe Sullivan